Purpose: Rhabdomyolysis is a potentially life-threatening condition in which skeletal muscle rapidly deteriorates leading to a biochemical syndrome with approximately 26,000 cases reported annually within the US alone. The purpose of this entry is to understand the pathophysiology of rhabdomyolysis and its implications in geriatric populations.1,2,3,4,5
Learning Objectives: 1. Understand pathophysiology of Rhabdomyolysis 2. Learn the causes and risk factors of Rhabdomyolysis. 3. Learn to recognize the signs, symptoms, and diagnosis of Rhabdomyolysis. 4. Learn about the management and treatment of Rhabdomyolysis.
Pathophysiology:
“Rhabdomyolysis is defined as necrosis of skeletal muscle fibers with release of fiber contents into the blood and urine.”2 Rhabdomyolysis may occur as a primary or secondary disorder stemming from inherited or abnormal muscles cells or as a secondary event following infection, toxic agents, or injury, respectively. Muscle fiber lysis, caused by damage to the walls of the muscle fiber, lead to abnormally high concentrations of free calcium ion inside of the muscle fiber. In a normally functioning cell, calcium levels are maintained in a normal range through the synergistic effects of transporters located on the sarcolemma and sarcoplasmic reticulum. Despite the initial cause of abnormal intracellular calcium, the abnormal level activates proteases and phospholipases leading to a breakdown of of structural proteins of the cell including the cell wall and cytoskeleton leading to a release of muscular wastes into the blood stream.1,2,3,4,5
Causes leading to the initial breakdown of ion homeostasis of the muscle fibers may include venom or toxin effects of alcohol on the cell membrane, inability to produce sufficient energy to fuel ion transporters, enzyme deficiencies, among others. More recently exertion-related causes of rhabdomyolysis are being increasingly reported.2,4 Severity of rhabdomyolysis tends to be depend on the presence and severity of kidney failure.
Rhabdomyolysis may cause death through several mechanisms as levels of waste in the blood increase to pathological levels. Several causes include increases in serum potassium leading to heart arrhythmias, renal failure secondary to intratubular obstruction, hyperthermia, volume depletion, leukocytosis, metabolic acidosis, anemia, or intravascular coagulation among other causes.
Causes and risk factors: Exercise-induced: may occur in athletes or patients with muscle wasting diseases. Exercise and fasting may increase risk in patients with muscle wasting disease.4 Crush syndrome: Initial crush injury causes severe muscle damage which is experienced systemically following restoration of blood flow from crushed body part to general circulation. Toxic agents, medications: A wide variety of medications and toxins can contribute to development of rhabdomyolysis. Examples include alcohol, statins, fibrates, antipsychotics, anesthesia, SSRIs, diuretics, heavy metals, hemlock, and more. Refer to Guis paper for further detail. Disrupted blood supply: arterial thrombosis, embolism, artery clamping. Other causes: Hyperthermia, disrupted metabolism, infection, inflammation.
Signs and symptoms2,3,5: Muscle fatigue Cramps Muscle pain and tenderness Weakness Increase in muscle size, swelling (sometimes) Nausea Vomiting Confusion Coma Abnormal heart rate and rhythm Decrease urine production Reddish-brown urine
Diagnosis2,3,5: Reddish-brown urine color >5-fold increase in serum creatine kinase (CPK) Increased urinary myoglobin concentration May present with increased serum potassium, urea, creatine, or muscle enzymes.
Treatment and management: First step of treatment for acute rhabdomyolysis is to rehydrate the patient. In severe rhabdomyolysis, with extreme metabolic disturbances and renal failure or dysfunction secondary to myoglobinuria, dialysis may be required. In cases of patients with chronic rhabdomyolysis the best practice for management includes avoiding those activities and situations which exacerbate the condition. Low intensity physical activity may be beneficial when the patient is stabilized in order to promote restoration of mitochondria.
References: 1. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009;361(1):62-72. 2. Guis S, Mattei JP, Cozzone PJ, Bendahan D. Pathophysiology and clinical presentations of rhabdomyolysis. Joint Bone Spine. 2005;72(5):382-391. 3. Sauret JM, Marinides G, Wang GK. Rhabdomyolysis. Am Fam Physician. 2002;65(5):907-912. 4. Tietze DC, Borchers J. Exertional rhabdomyolysis in the athlete: A clinical review. Sports Health. 2014;6(4):336-339. 5. Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. J Am Soc Nephrol. 2000;11(8):1553-1561.
Topics in Geriatrics:Rhabdomyolysis
Rhabdomyolysis is a condition in which skeletal muscle breaks down and releases harmful proteins into the blood. Geriatric patients can be susceptible to rhabdomyolysis due to side effects of medications and prolonged lying on the floor after a fall.
Objectives:
1. The reader will learn about the physiological process of rhabdomyolysis
2. The reader will understand how and why rhabdomyolysis is particularly relevant to the geriatric population
3. The reader will demonstrate knowledge of three or may different ways geriatric patients can develop rhabdomyolysis
4. The reader will learn about ways that rhabdomyolysis can be avoided and treated and in the geriatric population
Rhabdomyolysis is a condition in which skeletal muscle breaks down and releases harmful proteins into the blood. It can occur in the geriatric population as a result of complete immobilization resulting from acute illness (Marcus, 1992). In a study performed by Marcus (1992), 23 out of 2,870 patients admitted to the acute geriatric department of a university-affiliated teaching hospital had rhabdomyolysis. This represents an incidence of 0.8%. A patient was determined to have rhabdomyolysis if they had elevated serum creatine kinase of five times or greater above the upper reference limit and greater than 97% MM isoenzyme (Marcus, 1992). Of the 23 subjects positive for rhabdomyolysis in this study, 17 had renal failure.
In addition to complete immobilization resulting from an illness, rhabdomyolysis can also occur as the result of medications. As geriatric populations are more likely to display polypharmacy (Moylan, 2007), this is particularly relevant to elderly populations. In one report by Chattopadhyay (2001), a 74-year-old male presented with shortness of breath, nausea, and diffuse muscle aches and pains. The patient had a history of ischemic heart disease, atrial fibrillation, chronic congestive cardiac failure, and chronic gout. Due to a recent exacerbation of his gout, the patient had increased his dose of colchicine to 1.5 mg per day for six weeks leading up to his presentation. An adverse drug reaction to the man's elevated dose of colchicine caused the serious and potentially life threatening development of rhabdomyolysis in this patient (Chattopadhyay, 2001).
In another report by Merante (2010), an 87-year-old female presented with confusion, tremors, fever and an inability to walk. Excessive use of high dosage lactulose and sorbitol syrup as laxatives caused this patient to exhibit hypokalemia due to electrolytic imbalances and rhabdomyolysis associated with this imbalances (Merante, 2010). This is yet another reminded that careful monitoring of medications and new or unusual signs and symptoms in the geriatric population can be critical to healthcare professionals picking up on a serious and life threatening condition such as rhabdomyolysis.
Another potential cause of rhabdomyolysis in the elderly is prolonged immobility, not from acute sickness, but as the result of a fall. Moylan (2007) reports that nearly one third of people aged 65 and over fall at least once each year. Furthermore, in a separate study, Fleming (2008) reported that 82% of falls reported by the given geriatric population being studied occurred when the patient was alone. 80% of those who fell could not get up on their own and 30% laid on the floor for an hour or more (Fleming, 2008). This difficulty getting up was consistently associated with age, and lying on the floor for prolonged periods of time after a fall was associated with serious injuries, admission to the hospital, and subsequent moves into long term care (Fleming, 2008).
Because we know that elderly patients are at high risk for falls, physical therapists should consider ways to address this risk in their geriatric patients to decrease the risk of prolonged immobility resulting from a fall, resulting in rhabdomyolysis. Fleming (2008) suggests teaching patients strategies for getting themselves up off the floor if they were to fall. Moylan (2007) suggests a more preventive approach in screening patients for fall risk with tests such as the Romberg, single-leg-stance, and get-up-and-go tests. Moylan (2007) also suggests that geriatric patients be encouraged to remain active.
Physical therapists should be educated on the basic lab values and clinical signs and symptoms associated with rhabdomyolysis to help detect this condition, especially in elderly patients. Healthcare professionals can and should combat the increased risk for developing rhabdomyolysis in the geriatric population by addressing medication management, fall risk, and independent mobility in their elderly patients.
Resources
Chattopadhyay, I., Shetty, H. G., Routledge, P. A., & Jeffery, J. (2001). Colchicine induced rhabdomyolysis. Postgraduate Medical Journal, 77(905), 191–192.
Fleming, J., & Brayne, C. (2008). Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90. British Medical Journal, 337(a2227).
Marcus, E. L., Rudensky, B., & Sonnenblick, M. (1992). Occult Elevation of CK as a Manifestation of Rhabdomyolysis in the Elderly. Journal of the American Geriatrics Society, 40(5), 454–456.
Merante, A, et al. (2010). Laxative-induced rhabdomyolysis. Clinical Interventions in Aging, 5, 71–73.
Moylan, K. C., & Binder, E. F. (2007). Falls in Older Adults: Risk Assessment, Management and Prevention. The American Journal of Medicine, 120(6), 493–497.
Written by: Chris DeSanctis
Purpose: Rhabdomyolysis is a potentially life-threatening condition in which skeletal muscle rapidly deteriorates leading to a biochemical syndrome with approximately 26,000 cases reported annually within the US alone. The purpose of this entry is to understand the pathophysiology of rhabdomyolysis and its implications in geriatric populations.1,2,3,4,5
Learning Objectives:
1. Understand pathophysiology of Rhabdomyolysis
2. Learn the causes and risk factors of Rhabdomyolysis.
3. Learn to recognize the signs, symptoms, and diagnosis of Rhabdomyolysis.
4. Learn about the management and treatment of Rhabdomyolysis.
Pathophysiology:
“Rhabdomyolysis is defined as necrosis of skeletal muscle fibers with release of fiber contents into the blood and urine.”2 Rhabdomyolysis may occur as a primary or secondary disorder stemming from inherited or abnormal muscles cells or as a secondary event following infection, toxic agents, or injury, respectively. Muscle fiber lysis, caused by damage to the walls of the muscle fiber, lead to abnormally high concentrations of free calcium ion inside of the muscle fiber. In a normally functioning cell, calcium levels are maintained in a normal range through the synergistic effects of transporters located on the sarcolemma and sarcoplasmic reticulum. Despite the initial cause of abnormal intracellular calcium, the abnormal level activates proteases and phospholipases leading to a breakdown of of structural proteins of the cell including the cell wall and cytoskeleton leading to a release of muscular wastes into the blood stream.1,2,3,4,5
Causes leading to the initial breakdown of ion homeostasis of the muscle fibers may include venom or toxin effects of alcohol on the cell membrane, inability to produce sufficient energy to fuel ion transporters, enzyme deficiencies, among others. More recently exertion-related causes of rhabdomyolysis are being increasingly reported.2,4 Severity of rhabdomyolysis tends to be depend on the presence and severity of kidney failure.
Rhabdomyolysis may cause death through several mechanisms as levels of waste in the blood increase to pathological levels. Several causes include increases in serum potassium leading to heart arrhythmias, renal failure secondary to intratubular obstruction, hyperthermia, volume depletion, leukocytosis, metabolic acidosis, anemia, or intravascular coagulation among other causes.
Causes and risk factors:
Exercise-induced: may occur in athletes or patients with muscle wasting diseases. Exercise and fasting may increase risk in patients with muscle wasting disease.4
Crush syndrome: Initial crush injury causes severe muscle damage which is experienced systemically following restoration of blood flow from crushed body part to general circulation.
Toxic agents, medications: A wide variety of medications and toxins can contribute to development of rhabdomyolysis. Examples include alcohol, statins, fibrates, antipsychotics, anesthesia, SSRIs, diuretics, heavy metals, hemlock, and more. Refer to Guis paper for further detail.
Disrupted blood supply: arterial thrombosis, embolism, artery clamping.
Other causes: Hyperthermia, disrupted metabolism, infection, inflammation.
Signs and symptoms2,3,5:
Muscle fatigue
Cramps
Muscle pain and tenderness
Weakness
Increase in muscle size, swelling (sometimes)
Nausea
Vomiting
Confusion
Coma
Abnormal heart rate and rhythm
Decrease urine production
Reddish-brown urine
Diagnosis2,3,5:
Reddish-brown urine color
>5-fold increase in serum creatine kinase (CPK)
Increased urinary myoglobin concentration
May present with increased serum potassium, urea, creatine, or muscle enzymes.
Treatment and management:
First step of treatment for acute rhabdomyolysis is to rehydrate the patient. In severe rhabdomyolysis, with extreme metabolic disturbances and renal failure or dysfunction secondary to myoglobinuria, dialysis may be required. In cases of patients with chronic rhabdomyolysis the best practice for management includes avoiding those activities and situations which exacerbate the condition. Low intensity physical activity may be beneficial when the patient is stabilized in order to promote restoration of mitochondria.
References:
1. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009;361(1):62-72.
2. Guis S, Mattei JP, Cozzone PJ, Bendahan D. Pathophysiology and clinical presentations of rhabdomyolysis. Joint Bone Spine. 2005;72(5):382-391.
3. Sauret JM, Marinides G, Wang GK. Rhabdomyolysis. Am Fam Physician. 2002;65(5):907-912.
4. Tietze DC, Borchers J. Exertional rhabdomyolysis in the athlete: A clinical review. Sports Health. 2014;6(4):336-339.
5. Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. J Am Soc Nephrol. 2000;11(8):1553-1561.
Topics in Geriatrics: Rhabdomyolysis
Rhabdomyolysis is a condition in which skeletal muscle breaks down and releases harmful proteins into the blood. Geriatric patients can be susceptible to rhabdomyolysis due to side effects of medications and prolonged lying on the floor after a fall.
Objectives:
1. The reader will learn about the physiological process of rhabdomyolysis
2. The reader will understand how and why rhabdomyolysis is particularly relevant to the geriatric population
3. The reader will demonstrate knowledge of three or may different ways geriatric patients can develop rhabdomyolysis
4. The reader will learn about ways that rhabdomyolysis can be avoided and treated and in the geriatric population
Rhabdomyolysis is a condition in which skeletal muscle breaks down and releases harmful proteins into the blood. It can occur in the geriatric population as a result of complete immobilization resulting from acute illness (Marcus, 1992). In a study performed by Marcus (1992), 23 out of 2,870 patients admitted to the acute geriatric department of a university-affiliated teaching hospital had rhabdomyolysis. This represents an incidence of 0.8%. A patient was determined to have rhabdomyolysis if they had elevated serum creatine kinase of five times or greater above the upper reference limit and greater than 97% MM isoenzyme (Marcus, 1992). Of the 23 subjects positive for rhabdomyolysis in this study, 17 had renal failure.
In addition to complete immobilization resulting from an illness, rhabdomyolysis can also occur as the result of medications. As geriatric populations are more likely to display polypharmacy (Moylan, 2007), this is particularly relevant to elderly populations. In one report by Chattopadhyay (2001), a 74-year-old male presented with shortness of breath, nausea, and diffuse muscle aches and pains. The patient had a history of ischemic heart disease, atrial fibrillation, chronic congestive cardiac failure, and chronic gout. Due to a recent exacerbation of his gout, the patient had increased his dose of colchicine to 1.5 mg per day for six weeks leading up to his presentation. An adverse drug reaction to the man's elevated dose of colchicine caused the serious and potentially life threatening development of rhabdomyolysis in this patient (Chattopadhyay, 2001).
In another report by Merante (2010), an 87-year-old female presented with confusion, tremors, fever and an inability to walk. Excessive use of high dosage lactulose and sorbitol syrup as laxatives caused this patient to exhibit hypokalemia due to electrolytic imbalances and rhabdomyolysis associated with this imbalances (Merante, 2010). This is yet another reminded that careful monitoring of medications and new or unusual signs and symptoms in the geriatric population can be critical to healthcare professionals picking up on a serious and life threatening condition such as rhabdomyolysis.
Another potential cause of rhabdomyolysis in the elderly is prolonged immobility, not from acute sickness, but as the result of a fall. Moylan (2007) reports that nearly one third of people aged 65 and over fall at least once each year. Furthermore, in a separate study, Fleming (2008) reported that 82% of falls reported by the given geriatric population being studied occurred when the patient was alone. 80% of those who fell could not get up on their own and 30% laid on the floor for an hour or more (Fleming, 2008). This difficulty getting up was consistently associated with age, and lying on the floor for prolonged periods of time after a fall was associated with serious injuries, admission to the hospital, and subsequent moves into long term care (Fleming, 2008).
Because we know that elderly patients are at high risk for falls, physical therapists should consider ways to address this risk in their geriatric patients to decrease the risk of prolonged immobility resulting from a fall, resulting in rhabdomyolysis. Fleming (2008) suggests teaching patients strategies for getting themselves up off the floor if they were to fall. Moylan (2007) suggests a more preventive approach in screening patients for fall risk with tests such as the Romberg, single-leg-stance, and get-up-and-go tests. Moylan (2007) also suggests that geriatric patients be encouraged to remain active.
Physical therapists should be educated on the basic lab values and clinical signs and symptoms associated with rhabdomyolysis to help detect this condition, especially in elderly patients. Healthcare professionals can and should combat the increased risk for developing rhabdomyolysis in the geriatric population by addressing medication management, fall risk, and independent mobility in their elderly patients.
Resources
Chattopadhyay, I., Shetty, H. G., Routledge, P. A., & Jeffery, J. (2001). Colchicine induced rhabdomyolysis. Postgraduate Medical Journal, 77(905), 191–192.
Fleming, J., & Brayne, C. (2008). Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90. British Medical Journal, 337(a2227).
Marcus, E. L., Rudensky, B., & Sonnenblick, M. (1992). Occult Elevation of CK as a Manifestation of Rhabdomyolysis in the Elderly. Journal of the American Geriatrics Society, 40(5), 454–456.
Merante, A, et al. (2010). Laxative-induced rhabdomyolysis. Clinical Interventions in Aging, 5, 71–73.
Moylan, K. C., & Binder, E. F. (2007). Falls in Older Adults: Risk Assessment, Management and Prevention. The American Journal of Medicine, 120(6), 493–497.